2018 Individual & Family Plan Information

In honoring our commitment to the Sentara mission to improve health every day, Optima Health will stay in the ACA Exchange and continue to offer Individual plans for 2018. As a result of marketplace changes, we must withdraw from some markets and raise rates in order to stay in the ACA Exchange. While this is not the outcome we had hoped, it will allow us to continue to serve 80% of our existing members and provide an option for another 70,000 Virginians who are losing their current insurance plans. We will continue to serve our existing markets with our employer-based, Medicare and Medicaid plans.

Frequently Asked Questions on Coverage, Premiums, and Transition of Care

We realize you may have questions about your coverage based on these changes. Please see the question and answers below for answers to common questions.

Will my prescription drugs be covered by OptimaFit?

Do I qualify for a subsidy?

*Note: This tool provides a quick view of income levels that qualify for savings in 2018. In certain cases, individuals may qualify at different levels. You’ll find out exactly how much you'll save and pay for a plan when you fill out a Marketplace application.

Premium Questions

Why are your rates increasing?

From day one, our desire has been to offer coverage options for individuals and families in Virginia. With the uncertainty in Washington, and other carriers withdrawing from the market or reducing their service area, we have tried to offer coverage for as many Virginians as possible. No one is happy with the current rate structure, but we are working in an environment, including the Exchange, that is not operating as originally designed. Historically, Optima Health members have had far greater healthcare costs than originally envisioned. As a not-for-profit organization, we are committed to doing our very best to meet the needs of our communities, but we also must remain able to fulfill the obligations we have made to many more across the state.

The only other alternative would have been to completely exit the Exchange and the individual market, which goes against our mission to improve health every day.

What specifically made premiums higher for 2018?

Each person and family’s premium is unique to them based on the plan they have chosen. For this reason, we are unable to share specific information as to a particular increase. Overall, our rates are based on consulting with a national actuarial firm to help predict the cost of member health care expenses for the coming year.

The Affordable Care Act regulates how health insurance premiums are calculated, so there are many state and federal guidelines we are required to follow when determining our members’ new premiums. These include:

Where you live

How old you are

If you use tobacco

The type of plan you have

Number of dependents on the plan

At the same time, there was a federal mandate that changed the way that the rates are structured for children (under the age of 21). This means that families with dependent children under the age of 21 had higher than normal increases no matter where they live or which health plan they choose.

Our 2018 rates for Individual plans were also filed assuming the cost-sharing reductions (CSRs) were not going to be paid. The Trump Administration has since confirmed this benefit would be ending.

I receive a subsidy and the monthly premium amount in my 2018 renewal letter looks higher than it should be… why is that?

Your renewal letter provides only an estimate of the amount you will pay each month in 2018. This estimate is based on current information we have now, including the amount of financial help you received in 2017. It was calculated by subtracting your current 2017 subsidy from your new, 2018 premium. To find out how much financial help you qualify for in 2018 and your new premium amount, update your Marketplace application at www.healthcare.gov. If you are self-employed, you should be sure to contact your broker or one of our Personal Plan Advisors for guidance in calculating your reportable income. Our Personal Plan Advisors can be reached at 1-866-659-0892.

Is there anything I can do to lower my rates?

You may be eligible for savings. We have had several members who didn’t know that they qualified for subsidies or alternative plans. It is well worth the time to see if you qualify for subsidies and to learn about all of the plans available to you.

We know that this can be confusing and there are many ways to connect with someone to help you through the process:

If you have an insurance broker, the best thing you can do is to contact them. They can work with you to find the best match for your personal needs.

If you do not have a broker, call us at 1-866-659-0892. You may also email your question to us. Please include your first and last name in an email to members@optimahealth.com

What is the deadline?

You must take action no later than December 15, 2017 if you wish to make changes or choose a new plan for a January 1, 2018 effective date. If you wish to keep your current plan for 2018, you do not have to do anything. You will be automatically renewed into your current or an equivalent plan beginning January 1, 2018. It is best to update your information on www.healthcare.gov because it might help lower your rate. You can also reach out to your broker to talk through options before automatically renewing the plan that is in your letter. If you do not have a broker, call us at 1-866-659-0892.

Are there other assistance plans available?

Depending on your income, you may be eligible for Medicaid, the state-federal program for the poor and disabled. Low-income adults, including those without children, will be eligible as long as their income doesn’t exceed 133% of the Federal Poverty Level, or $15,800 for individuals and $32,319 for a family of four, according to current poverty guidelines.

Medicare is the insurance plan available to all citizens when they turn age 65.

Transition of Care

I will be covered by a new plan in 2018 and I have ongoing treatments – How will this transition be managed?

After your coverage under the Individual plan ends, your new carrier will be responsible to approve and pay for any ongoing treatments. We will work with our members to facilitate the approval and transition of care.

What if I’m in a treatment plan (PT/OT/Chemo/Home Health) when my plan ends on December 31?

You should work with your doctor to ensure authorizations for treatment plans are transferred to your new health plan.

What if I lose Optima Health Individual & Family plan coverage in the middle of receiving treatments for a chronic condition or pregnancy?

After your coverage under the Individual plan ends, your new carrier will be responsible to approve and pay for any ongoing treatments.